Monday, 10 September 2007


One of my partners, an excellent and caring GP on whom we have long relied as a rock of the practice, went on sick leave today due to stress. Another partner is away on holiday, but no doubt we shall cope. This follows on from my own bout of depression last year, although I managed to keep going despite feeling horrible. And a third partner has been struggling with the demands of the job for a long time. We are not conspicuously happy bunnies.
Turning and turning in the widening gyre
The falcon cannot hear the falconer;
Meanwhile, we keep getting warning messages every time we log on to our clinical computer system. Our licence expired at the end of June, and the warnings point out that unless the licence fee is paid soon the software will stop working on 30th September. That means that we will no longer be able to access our clinical records or issue repeat prescriptions for our patients. It would be almost impossible to practise medicine safely. Under our new contract it is the PCT who are responsible for paying this fee. Our practice manager has been emailing the four people who might be able to help for several weeks, and getting nothing but “out of office” messages saying that they will be unavailable indefinitely. The PCT has been reorganised yet again, many people have left and the new people do not know what they are doing. I also hear (both from my practice manager and from a consultant friend) that the hospital medical secretaries are leaving in droves. Those that remain are now in a typing pool and no longer accept responsibility for any consultant's patients. It is becoming almost impossible to chase things up and find out what is happening to our patients' hospital care. A strategy intended to save a little money will have a significant and possibly dangerous impact on patient care. And out of hours care, that used to be effectively run by GP co-operatives, is now run on the cheap by PCTs using nurses and computer protocols to replace doctors wherever possible. My consultant friend also tells me that all the Matrons at his hospital were recently told to reapply for their jobs, and half of them were made redundant. He did not think this was a good way to treat respected senior nursing colleagues. And the effect of Choose and Book has been to destroy his sub-specialist clinic (since patients can no longer be referred to him by name) and he has lost contact with all the patients he had been following up for fifteen years.
Things fall apart; the center cannot hold;
Mere anarchy is loosed upon the world,
But to listen to the politicians one would believe that all was for the best in the best of all possible health systems. Lessons will be learned from any minor problems that may currently exist, and every day in every way the NHS is getting better and better. The politicians may have caused significant harm to junior doctors and their training by the recent MMC/MTAS fiasco, but they don't seem particularly worried. Panglossian reports and mission statements paint a picture of a health service that I don't recognise. And the Government are currently blaming GPs for the effects of the contract that they forced upon us three years ago, and now want us to work even harder. Many of us doubt the impartiality of the General Medical Council who have decided that the burden of proof in fitness-to-practice cases will be reduced from “beyond reasonable doubt” to “balance of probabilities”. Having made that decision they have the chutzpah to consult us on the exact wording, which is rather like asking turkeys to vote on the merits of stuffing and cranberry sauce. We are also promised that appraisal and revalidation will be toughened up, to keep us on our toes and deter us from our serial-killing aspirations. All this will do nothing to improve the mental health of the doctors in our practice.
The best lack all conviction, while the worst
Are full of passionate intensity.
So what's to do? My consultant friend went through a sticky patch of mental health recently when faced with the destruction of his sub-specialist clinic, the barriers to his research, the loss of his secretary, and many other measures which affected his ability to provide first class care and carry out first class research. Despite being a professor with good interpersonal skills, he got nowhere when trying to discuss these problems with the hospital management. Similarly I think that my depression was caused in part by the fact that I had been vehemently opposed to the new GP contract. I had even played a small part in campaigning against the contract, but all was in vain. The Government were adamant that the new contract must be accepted, and agreed the necessary compromises with our negotiators to ensure that GPs would vote for it. I suspect that the sense of failure and powerlessness that this caused was at the root of my depression.

One of my patients has a paranoid personality disorder and was always getting into trouble. He would misinterpret events and think that people were getting at him. He has been banned from his local supermarket because he argued with some workmen there, and has had a similar disagreement with staff at his bank. However with the passage of time and prescription of zuclopentixol he has improved. “I've learned from experience” he told me recently. “I don't argue any more, it just gets me into more trouble”. My consultant friend is less paranoid, but he has also learned from experience. “I don't try to argue any more” he told me, “I just get on with doing the best I can for the patient sitting in front of me at the time.” I take much the same line myself. We seem to be suffering from learned helplessness and, by heck, we've had some good teachers!


The Shrink said...

In my first few weeks as a Consultant the Medical Director shared wise counsel with me.

"Over the years," he said, "I've learnt it's far easier to ask for forgiveness than permission."

We do what seems sensible for our patients and benignly concede wayward disregard for protocol if anyone does pick it up.

No, I'm not too maverick, but this has indeed stood me in good stead :-)

Anonymous said...

I can sympathise, but on the other hand the issues you describe are just called work to the rest of the world. No-one else gets to dictate terms, everyone else has to just bite the bullet when it comes to reorganisations and a lot of us are working very long hours and making about a quarter of your salary.
I don't doubt it's dispiriting, but I've spent my whole 20 year career being similarly dispirited.

Anonymous said...

I read or heard once that hope is the belief that what you are doing will make a difference. The original context was, I think, prayer, but I've found that it applies well to life in general.

I've found that feelings of futility and helplessness make work infinitely more stressful. Far better to take the shrink's advice (we sailors call this the Navy way), especially at this fairly senior point in your career, and do what you think is best for your patients.

Dr Andrew Brown said...

Thanks for all the interesting ideas. "The Navy way" - that would be "I really do not see the signal", I suppose. :-)